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Sims OT, Wang K, Chandler R, Melton PA, Truong DN. A descriptive analysis of concurrent alcohol and substance use among patients living with HIV/HCV co-infection. SOCIAL WORK IN HEALTH CARE 2020; 59:525-541. [PMID: 32873213 PMCID: PMC9494867 DOI: 10.1080/00981389.2020.1814938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The objectives of this study were to estimate the prevalence of concurrent alcohol and substance use among patients living with HIV/HCV co-infection and to compare demographic and clinical characteristics of those with concurrent alcohol and substance to those with alcohol or substance use, and to those who were abstinent. We conducted an analysis of patient reported outcomes data of patients living with HIV/HCV co-infection (n = 327) who transitioned from primary care to sub-specialty care for evaluation of candidacy for HCV treatment at a university-affiliated HIV Clinic. The prevalence of self-reported concurrent alcohol and substance use was 33%. A higher proportion of those with concurrent alcohol and substance use were currently smoking tobacco, and those who were abstinent had higher ratings of health-related quality of life compared to those with alcohol or substance use. To reduce patients' risk for progression to advanced stages of HIV, HCV, and liver-related disease due to continued alcohol and substance and tobacco use, social workers and other health care professionals are encouraged to develop and implement intervention strategies to assist patients living with HIV/HCV co-infection in efforts to achieve behavioral change.
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Affiliation(s)
- Omar T Sims
- Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham , Birmingham, AL, USA
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham , Birmingham, AL, USA
- Integrative Center for Healthy Aging, School of Medicine, University of Alabama at Birmingham , Birmingham, AL, USA
- Center for AIDS Research, School of Medicine, University of Alabama at Birmingham , Birmingham, AL, USA
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California San Francisco , San Francisco, CA, USA
| | - Kaiying Wang
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham , Birmingham, AL, USA
- Department of Mathematics and Statistics, College of Arts and Sciences, Georgia State University , Atlanta, GA, USA
| | - Rasheeta Chandler
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California San Francisco , San Francisco, CA, USA
- School of Nursing, Emory University , Atlanta, GA, USA
| | - Pamela A Melton
- School of Social Work, Tulane University , New Orleans, LA, USA
| | - Duong N Truong
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham , Birmingham, AL, USA
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Elliott JC, Shalev N, Hasin DS. Medical Reasons for Limiting Drinking: Data from a Sexual Health Clinic. Subst Use Misuse 2019; 54:967-972. [PMID: 30618338 PMCID: PMC6476630 DOI: 10.1080/10826084.2018.1555255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Heavy drinking poses health risks for individuals with HIV, and some individuals with HIV attempt to reduce drinking. Little is known about whether medical reasons motivate HIV-infected individuals to reduce drinking. OBJECTIVES We evaluated medical reasons for limiting drinking among patients in a sexual health clinic, and explored whether these reasons could be operationalized as a new scale for research and clinical use in sexual health clinics. METHODS A sample of 70 patients in a sexual health clinic who reported efforts to limit drinking in the past month (84% with self-reported HIV; 81% male; 50% Black) completed a nine-item medical reasons for limiting drinking scale on a tablet while waiting for their appointment. Exploratory factor analysis was performed to evaluate psychometric properties of the scale. RESULTS Patients most commonly endorsed general concerns about health, and concerns about alcohol's effect on the liver. Support was found for a unidimensional (one-factor) eight-item scale, which evidenced good internal consistency (α = 0.84). Results were identical when analyses were restricted to the subset of 59 individuals who self-reported HIV infection. Conclusions/Importance: This study suggests that individuals in a sexual health clinic most commonly endorse broad nonspecific concerns about drinking and health, as well as concerns about their liver. This study yields an 8-item scale to measure medical reasons for limiting drinking in sexual health clinics and among individuals with HIV. This scale should enhance researchers' ability to study this important construct and may facilitate discussion of drinking reduction with HIV-infected heavy drinkers, requiring future study.
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Affiliation(s)
- Jennifer C Elliott
- a New York State Psychiatric Institute , New York , New York , USA.,b Department of Psychiatry , Columbia University Medical Center , New York , New York , USA
| | - Noga Shalev
- c Division of Infectious Diseases , Columbia University Medical Center , New York , New York , USA
| | - Deborah S Hasin
- a New York State Psychiatric Institute , New York , New York , USA.,b Department of Psychiatry , Columbia University Medical Center , New York , New York , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , New York , USA
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3
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Knox J, Wall M, Witkiewitz K, Kranzler HR, Falk D, Litten R, Mann K, O'Malley SS, Scodes J, Anton R, Hasin DS. Reduction in Nonabstinent WHO Drinking Risk Levels and Change in Risk for Liver Disease and Positive AUDIT-C Scores: Prospective 3-Year Follow-Up Results in the U.S. General Population. Alcohol Clin Exp Res 2018; 42:2256-2265. [PMID: 30204248 PMCID: PMC6263142 DOI: 10.1111/acer.13884] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/04/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Abstinence is often the treatment aim for alcohol use disorders (AUD), but this may deter individuals who prefer drinking reduction goals from entering treatment, and be an overly restrictive end point in alcohol clinical trials. Nonabstinent drinking reductions that predict improvement in how individuals feel or function may be useful clinical trial outcomes, for example, reductions in the 4-category World Health Organization (WHO) drinking risk levels. To investigate the clinical relevance of these reductions, we examined their relationship with 2 outcomes of interest to medical providers: liver disease, and positive scores on an alcohol screening measure. METHODS Current drinkers in a U.S. national survey (n = 21,925) were interviewed in 2001 to 2002 (Wave 1) and re-interviewed 3 years later (Wave 2). WHO drinking risk levels, liver disease, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were assessed at both waves. Adjusted odds ratios (aORs) were used to indicate the association of change in WHO drinking risk levels with Wave 2 liver disease and AUDIT-C scores. RESULTS Wave 1 very-high-risk drinkers who reduced 1, 2, or 3 WHO drinking risk levels had significantly lower odds of Wave 2 liver disease (aORs = 0.34, 0.23, 0.17) and positive AUDIT-C scores (aORs = 0.27, 0.09, 0.03). Wave 1 high-risk drinkers who reduced 1 or 2 WHO risk levels had significantly lower odds of positive AUDIT-C scores (aORs = 0.61, 0.25). Adjusting for alcohol dependence or AUDIT-C scoring variations did not affect results. CONCLUSIONS In the highest-risk drinkers, reductions in WHO drinking risk levels predicted lower likelihood of liver disease and positive AUDIT-C scores. Results add to findings that reductions in the 4-category WHO drinking risk levels are a meaningful indicator of how individuals feel and function, and could serve as nonabstinent end points in clinical trials. Results also connect the WHO risk drinking levels to commonly used alcohol screening questions, which may be more familiar to healthcare providers.
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Affiliation(s)
- Justin Knox
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
| | - Melanie Wall
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Biostatistics, Columbia University Medical Center, New York, New York
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Henry R Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel Falk
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Raye Litten
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Karl Mann
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | | | - Raymond Anton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
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The Importance of Context: Neighborhood Drinking Norms and Heavy Drinking Among HIV Patients. J Acquir Immune Defic Syndr 2018; 72:e55-7. [PMID: 26959191 DOI: 10.1097/qai.0000000000000982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Scott-Sheldon LAJ, Carey KB, Johnson BT, Carey MP. Behavioral Interventions Targeting Alcohol Use Among People Living with HIV/AIDS: A Systematic Review and Meta-Analysis. AIDS Behav 2017; 21:126-143. [PMID: 28831609 PMCID: PMC5660648 DOI: 10.1007/s10461-017-1886-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Alcohol use is often reported among people living with HIV/AIDS (PLWHA) and is associated with increased sexual risk and poor medication adherence. This meta-analysis evaluated the efficacy of behavioral interventions addressing alcohol use among PLWHA. Twenty-one studies (N = 8461 PLWHA) that evaluated an individual-level intervention addressing alcohol use alone or as part of a more comprehensive alcohol/HIV intervention, included a control condition, and were available through December 2016 were included. Independent raters coded study, sample, and intervention content. Weighted mean effect sizes, using random-effects models, were calculated. Results indicate that interventions reduced alcohol consumption, increased condom use, and improved medication adherence relative to controls (d +s = 0.10-0.24). Plasma viral load was also reduced in intervention versus control participants (d + = 0.14, 95% CI = 0.02, 0.26; k = 7). These findings show that behavioral interventions addressing alcohol use can successfully reduce alcohol consumption and also improve HIV-related outcomes among PLWHA.
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Affiliation(s)
- Lori A J Scott-Sheldon
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, CORO Building, Suite 309, 164 Summit Ave., Providence, RI, 02906, USA.
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI, USA.
- Department of Behavioral and Social Sciences, Brown School of Public Health, Providence, RI, USA.
| | - Kate B Carey
- Brown School of Public Health, Center for Alcohol and Addiction Studies, Providence, RI, USA
| | - Blair T Johnson
- Department of Psychology, University of Connecticut, Storrs, CT, USA
| | - Michael P Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, CORO Building, Suite 309, 164 Summit Ave., Providence, RI, 02906, USA
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI, USA
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Christensen B, Qin Z, Byrd DA, Yu F, Morgello S, Gelman BB, Moore DJ, Grant I, Singer EJ, Fox HS, Baccaglini L. Measures of Physical and Mental Independence Among HIV-Positive Individuals: Impact of Substance Use Disorder. AIDS Res Hum Retroviruses 2017; 33:1048-1055. [PMID: 28288515 DOI: 10.1089/aid.2016.0269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
With the transition of HIV infection from an acute to a chronic disease after the introduction of antiretroviral medications, there has been an increased focus on long-term neurocognitive and other functional outcomes of HIV patients. Thus, we assessed factors, particularly history of a substance use disorder, associated with time to loss of measures of physical or mental independence among HIV-positive individuals. Data were obtained from the National NeuroAIDS Tissue Consortium. Kaplan-Meier and Cox proportional hazards regression analyses were used to estimate the time since HIV diagnosis to loss of independence, and to identify associated risk factors. HIV-positive participants who self-identified as physically (n = 698) or mentally (n = 616) independent on selected activities of daily living at baseline were eligible for analyses. A history of substance use disorder was associated with a higher hazard of loss of both physical and mental independence [adjusted hazard ratio (HR) = 1.71, 95% confidence interval (95% CI): 1.07-2.78; adjusted HR = 1.67, 95% CI: 1.11-2.52, respectively]. After adjusting for substance use disorder and other covariates, older age at diagnosis and female gender were associated with higher hazards of loss of both physical and mental independence, non-white participants had higher hazards of loss of physical independence, whereas participants with an abnormal neurocognitive diagnosis and fewer years of education had higher hazards of loss of mental independence. In summary, history of substance use disorder was associated with loss of measures of both physical and mental independence. The nature of this link and the means to prevent such loss of independence need further investigation.
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Affiliation(s)
- Bianca Christensen
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Zijian Qin
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Desiree A. Byrd
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fang Yu
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin B. Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas
- Department of Neuroscience and Cell Biology, University of Texas Medical Branch, Galveston, Texas
| | - David J. Moore
- Department of Psychiatry, School of Medicine, University of California San Diego, San Diego, California
| | - Igor Grant
- Department of Psychiatry, School of Medicine, University of California San Diego, San Diego, California
| | - Elyse J. Singer
- Department of Neurology, School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Howard S. Fox
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Lorena Baccaglini
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
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Edelman EJ, Hansen NB, Cutter CJ, Danton C, Fiellin LE, O'Connor PG, Williams EC, Maisto SA, Bryant KJ, Fiellin DA. Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics. Addict Sci Clin Pract 2016; 11:1. [PMID: 26763048 PMCID: PMC4711105 DOI: 10.1186/s13722-015-0048-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022] Open
Abstract
Background
Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists. Methods We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes. Results From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention. Conclusions Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Nathan B Hansen
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA. .,College of Public Health, University of Georgia, 131 Wright Hall, Health Sciences Campus, Athens, GA, 30602, USA.
| | - Christopher J Cutter
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Cheryl Danton
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Lynn E Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Patrick G O'Connor
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Emily C Williams
- VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA, 98101, USA. .,Department of Health Services, University of Washington, 1959 NE Pacific Street, Magnuson Health Sciences Center, Room H-664, Seattle, WA, 98195, USA.
| | - Stephen A Maisto
- Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244, USA.
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, 5635 Fishers Lane, Bethesda, MD, 20892-7003, USA.
| | - David A Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
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Elliott JC, Aharonovich E, Hasin DS. Post-treatment drinking among HIV patients: Relationship to pre-treatment marijuana and cocaine use. Drug Alcohol Depend 2015; 151:115-20. [PMID: 25920801 PMCID: PMC5030768 DOI: 10.1016/j.drugalcdep.2015.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/11/2015] [Accepted: 03/09/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND For individuals with HIV, heavy drinking can pose serious threats to health. Some interventions are effective at reducing drinking in this population, but many HIV-infected heavy drinkers also use marijuana or cocaine. Although these drugs have predicted poor alcohol outcomes in other treatment studies, whether this occurs among HIV patients who drink heavily is unknown. METHODS Participants were binge-drinking HIV primary care patients (N=254) enrolled in a randomized trial of three brief drinking interventions over 60 days that varied in intensity. We investigated the relationship of baseline past-year drug use (marijuana-only, cocaine-only, both, neither) to end-of-treatment drinking quantity and frequency. We also evaluated whether the relationship between intervention type and end-of-treatment drinking varied by baseline drug use. Final models incorporated control for patients' demographic and HIV characteristics. RESULTS In final models, drinking frequency at the end of treatment did not vary by baseline drug use, but drinking quantity did (X(2)[3] = 13.87, p < 0.01), with individuals using cocaine-only drinking significantly more per occasion (B = 0.32, p < 0.01). Baseline drug use also interacted with intervention condition in predicting end-of-treatment drinking quantity (X(2)[6] = 13.98, p < 0.05), but not frequency, with the largest discrepancies in end-of-treatment drinks per drinking day by intervention intensity among cocaine-only patients. CONCLUSIONS In general, HIV patients using cocaine evidenced the highest levels of drinking after alcohol intervention. However, these individuals also evidenced the most pronounced differences in end-of-treatment drinking by intervention intensity. These results suggest the importance of more intensive intervention for individuals using alcohol and cocaine.
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Affiliation(s)
- Jennifer C. Elliott
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032, USA
| | - Efrat Aharonovich
- Department of Psychiatry, Columbia University Medical Center, 180 Ft. Washington Avenue, New York, NY 10032, USA,New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032, USA,Department of Psychiatry, Columbia University Medical Center, 180 Ft. Washington Avenue, New York, NY 10032, USA,New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA
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Sundararajan R, Wyatt MA, Woolf-King S, Pisarski EE, Emenyonu N, Muyindike WR, Hahn JA, Ware NC. Qualitative study of changes in alcohol use among HIV-infected adults entering care and treatment for HIV/AIDS in rural southwest Uganda. AIDS Behav 2015; 19:732-41. [PMID: 25323678 PMCID: PMC4392168 DOI: 10.1007/s10461-014-0918-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18 years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.
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